What goes in the Subjective section of a SOAP note?

Patient-reported information: what the patient said about their mood, symptoms, recent events, sleep, appetite, stressors, side effects, and goals. Direct quotations are common (e.g., 'I've been crying every day'). The chief complaint, history of present illness updates, and any reported scale interpretations from the patient's perspective also belong here.

What goes in the Objective section of a SOAP note?

Observable data: mental status exam findings, behavioral observations (eye contact, psychomotor activity, affect), validated scale scores (PHQ-9, GAD-7, PCL-5), test results, vital signs if measured, and reports from collateral sources. The Objective section should describe what was measured or observed, not interpreted.

What goes in the Assessment section of a SOAP note?

Clinical interpretation: the clinician's synthesis of the Subjective and Objective data into a clinical picture. Includes ICD-11 diagnosis (or differential), severity assessment, scale interpretation in context, change from prior visits, comorbidities, and treatment response evaluation. This is where you reason from the data toward clinical decisions.

What goes in the Plan section of a SOAP note?

What's next: treatment recommendations, medication adjustments, therapeutic interventions to deploy, frequency of follow-up, referrals, scales to readminister, between-session homework, and any urgent action steps (safety planning, crisis resources). Each item should be specific enough that another clinician could continue care from your note alone.

What is an example of a SOAP note for therapy?

S: Patient reports persistent low mood for 3 weeks, sleep onset latency 2 hours, lost interest in usual hobbies. O: PHQ-9 score 16 (moderately severe), affect constricted, eye contact appropriate, no SI. A: F33.1 Major Depressive Disorder, Recurrent, Moderate, current episode partially responsive to sertraline 100mg. P: Continue sertraline; add behavioral activation worksheet; readminister PHQ-9 next session; follow up in 1 week.

How is a SOAP note different from a DAP note?

SOAP separates Subjective (what the patient reports) from Objective (what the clinician observes and measures), then proceeds to Assessment and Plan. DAP collapses Subjective and Objective into a single Data section. SOAP is preferred in multi-disciplinary settings, payer-friendly defaults, and presentations where the gap between self-report and observation is diagnostically meaningful. DAP is faster to write and common in private practice and outpatient psychotherapy.

When should I use a SOAP note in mental health practice?

SOAP is the safest default across U.S. behavioral health settings because it is the most familiar format to payers, auditors, and other treating clinicians. Use SOAP for medication management visits, intake evaluations, psychotherapy sessions in multi-disciplinary clinics, and any context where claims may be audited. Choose BIRP when interventions are the audit focus (case management, IOP) or DAP when private-practice efficiency outweighs the structural detail.

SOAP Notes for Therapists, Format, Examples, and Template

Q: What does SOAP stand for in therapy notes?

SOAP stands for Subjective, Objective, Assessment, and Plan. It is the most widely used clinical documentation format across medicine and behavioral health, originating in the 1970s problem-oriented medical record (POMR) movement. The four-part structure separates patient-reported information, observable data, the clinician's clinical reasoning, and the next steps.

The most widely used clinical documentation format in mental health. Subjective, Objective, Assessment, Plan, four sections, one consistent structure that supports both reimbursement and continuity of care.

SOAP structure breakdown

SSubjective

What the patient reports, symptoms, mood, recent stressors, sleep, appetite, side effects, goals. Direct quotations are common. The patient's voice.

OObjective

Observable data, mental status exam, validated scale scores, behavioural observations, vital signs (if measured), collateral reports. What was measured or observed, not interpreted.

AAssessment

The clinician's interpretation, ICD-10 diagnosis, severity, scale interpretation in context, change from prior visit, treatment response. Reasoning from the data.

PPlan

Next steps, interventions, medication changes, follow-up frequency, referrals, scales to readminister, homework, safety planning. Specific enough to support continuity of care.

Example: established-patient depression follow-up

Date: 2026-04-24 Time: 14:00–14:45 (45 min, 90834) Diagnosis: F33.1 Major Depressive Disorder, Recurrent, Moderate Patient: J.D., established, age 34 S: Subjective Patient reports mood "still pretty low most days but maybe a notch better than last visit." Sleep improved, averaging 6–7 hours from prior 4–5. Appetite normal. Denies SI. Reports starting morning walks 3×/week. Med tolerance good. No GI side effects on sertraline 100 mg. O: Objective PHQ-9 administered: 12 (down from 16 at last visit). GAD-7: 8 (down from 11). Affect: mildly constricted but more reactive than prior. Speech: normal rate, prosody. MSE: alert, oriented ×3. Insight and judgment intact. No suicidal ideation, plan, or intent. A: Assessment F33.1 in active treatment, showing clinically meaningful improvement (PHQ-9 -4 points). Comorbid F41.1 (GAD) also responsive. Activation behaviors (morning walks) consistent with behavioral activation strategy. No medication adverse effects to address. Risk: low. Item 9 negative, no recent ideation. P: Plan Continue sertraline 100 mg. Continue weekly behavioral-activation focused CBT. Reinforce activity scheduling. Re-administer PHQ-9 + GAD-7 at next visit (2026-05-01). Discussed sleep hygiene strategies. Patient to track activation goals between sessions. CPT: 90834 + 96127×2 (PHQ-9 + GAD-7)

This note bills 90834 (45-min psychotherapy) + 96127×2 (PHQ-9 and GAD-7 administration). The Objective section captures both scale scores; the Assessment integrates them with the prior visit. Both pieces are required by CPT 96127's documentation rules.

Copy-ready template

Date: ____ Time: ____ – ____ (___ min, CPT ____) Diagnosis: ____ (ICD-11) Patient: ____, ____ session S: Subjective [Patient-reported mood, symptoms, sleep, appetite, stressors, side effects, goals. Direct quotations welcome.] O: Objective [Mental status exam findings. Scale scores: PHQ-9 ___, GAD-7 ___, PCL-5 ___, AUDIT ___ (whichever administered). Behavioral observations.] A: Assessment [Clinical interpretation of S + O. Diagnosis confirmation or update. Severity, change from prior, treatment response. Risk assessment if relevant.] P: Plan [Interventions, medication changes, frequency, referrals, scales to re-administer, between-session tasks, safety planning.] CPT: ____ + 96127×__ (scales administered)

Documenting MBC scale scores in SOAP

For sessions billing CPT 96127, each scale unit billed must include in the note:

Scale name – typically in the Objective section ("PHQ-9 administered: 12").
Severity band – typically in the Objective or Assessment ("PHQ-9 = 12, moderate severity").
Change from prior administration – typically in Assessment ("PHQ-9 down 4 points from last visit, clinically meaningful").
Clinical interpretation and treatment-plan implication – Assessment + Plan ("Improvement consistent with behavioural activation strategy. Continue current treatment plan; readminister at next visit.").

Notes that record only the scale score without interpretation or integration into clinical decision-making are at risk of denial on audit. The clinician's reasoning is what 96127 reimburses, not the patient self-completing the form.

Common ICD-10 / CPT pairings for SOAP notes

The diagnosis (ICD-10) and service (CPT) drive what content the SOAP note must support. Common pairings:

F33.1 + 90834 + 96127×1 (PHQ-9), depression follow-up
F41.1 + 90834 + 96127×1 (GAD-7), anxiety follow-up
F43.10 + 90837 + 96127×1 (PCL-5), trauma-focused therapy (longer session common)
F10.20 + 90834 + 96127×1 (AUDIT), substance use treatment
Comorbid F33.1 + F41.1 + 90834 + 96127×2 (PHQ-9 + GAD-7), common comorbid presentation

Frequently asked questions

What does SOAP stand for in therapy notes?

Subjective, Objective, Assessment, Plan. The four-part structure separates patient-reported information, observable data, clinical reasoning, and next steps. Originated in the 1970s problem-oriented medical record movement.

What goes in the Subjective section?

What the patient said: mood, symptoms, stressors, sleep, side effects, goals. Direct quotations are encouraged.

What goes in the Objective section?

Mental status exam, validated scale scores (PHQ-9, GAD-7, PCL-5, AUDIT), behavioural observations, collateral reports. What was measured or observed — interpretation belongs in Assessment.

What goes in the Assessment section?

Your clinical reasoning: ICD-10 diagnosis, severity, how scores changed from the prior visit, and what those changes mean for the treatment plan. This is where S + O become a clinical picture.

What goes in the Plan section?

What happens next, specific enough for another clinician to continue care without calling you. Include any urgent action items such as safety planning or crisis referrals.

Sources & Citations

1.
Weed, L. L. (1968). Medical records that guide and teach. New England Journal of Medicine, 278(11), 593–600.
2.
U.S. Department of Health & Human Services. HIPAA Privacy Rule and Sharing Information Related to Mental Health.
3.
American Medical Association. Current Procedural Terminology (CPT) 2026, code 96127 documentation requirements.

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